Objectives Hemorrhage remains the leading cause of preventable trauma death. The assessment of blood consumption (ABC) score is simple to use but limited in prehospital settings due to its reliance on ultrasound. Reverse shock index multiplied by the simplified motor score (rSI-sMS) has shown promise by overcoming the limitations of shock index in elderly and traumatic brain injury (TBI) patients. However, no studies have directly compared the predictive performance of rSI-sMS and the ABC score for transfusion requirements and massive transfusion protocol (MTP) activation. Patients and methods: We performed a retrospective cohort study using data from the Japan Trauma Data Bank (2019–2023). The outcomes inclued MTP activation, 24-hour transfusion, advanced airway or circulatory interventions, and in-hospital mortality. Predictive performance of rSI-sMS (cutoff < 4) and the ABC score (cutoff ≥ 2) was evaluated using AUROC with DeLong tests, sensitivity, specificity, predictive values, likelihood ratios, overall accuracy, net reclassification improvement and integrated discrimination improvement. Subgroup analyses were conducted for elderly patients, cardiovascular disease, anticoagulant use, major trauma, and TBI. Results A total of 34,878 trauma patients were included in the analysis. Only a small proportion had prehospital (2.4%) or in-hospital (2.8%) ABC scores ≥ 2. The prediction accuracy of rSI-sMS consistently outperformed than ABC score in all clinical outcomes, including transfusion requirements (prehospital: 0.716 vs 0.641; in-hospital: 0.762 vs 0.668), MTP activation (0.764 vs 0.686; 0.817 vs 0.727), major injury (0.635 vs 0.549; 0.648 vs 0.564), advanced airway procedures (0.774 vs 0.611; 0.804 vs 0.647), advanced circulation procedures (0.632 vs 0.572; 0.649 vs 0.584), and mortality (0.784 vs 0.570; 0.827 vs 0.621), with in-hospital rSI-sMS showing the highest performance. Subgroup analyses further confirmed the superiority of rSI-sMS over the ABC score. rSI-sMS also demonstrated substantially higher sensitivity than ABC score for transfusion, MTP activation, and mortality (62–79% vs 7–20%), while maintaining moderate-to-high specificity (69–77% vs 98–99%). In-hospital rSI-sMS achieved the highest overall accuracy (73–75%), indicating the best balance between sensitivity and specificity. Conclusions Our study demonstrates that rSI-sMS significantly outperforms the ABC score in predicting major clinical outcomes, consistently showing superior performance across different trauma subgroups. However, large multicenter prospective studies are still required to validate its generalizability and effectiveness across diverse healthcare systems and patient populations.

Traumatic pancreatic injuries are uncommon but challenging to manage. This study aimed to clarify the clinical characteristics of traumatic pancreatic injury and explore the role of early endoscopic retrograde pancreatography (ERP) as a diagnostic and therapeutic approach. We reviewed 14 patients with traumatic pancreatic injuries treated between 2007 and 2025. Injuries were classified according to the Japanese Association for the Surgery of the Trauma System. Clinical outcomes were analyzed according to early ERP use (≤ 24 h after injury). Three patients had a type I injury, one had a type II injury, five had a type IIIa injury, and five had a type IIIb injury. Patients with a type IIIa/b injury had higher serum amylase levels at 24 and 48 h, as well as higher secondary intervention rates and longer hospital stays. Among five patients who underwent early ERP, the main pancreatic duct injury was successfully bridged in one patient with a type IIIb injury, enabling non-operative management. There were no significant differences in clinical outcomes between the early ERP and delayed/no ERP groups. Appropriate management of traumatic pancreatic injuries resulted in favorable outcomes. Further studies are required to clarify the clinical importance of early ERP.

Hepatic ischemia-reperfusion injury (IRI) is a critical clinical condition associated with liver transplantation and acute liver injury. This study investigated the role of sulfide quinone oxidoreductase (SQOR) and its downstream product, supersulfides, in hepatic IRI. C57BL/6NJ mice were subjected to 45 min of partial hepatic ischemia, followed by reperfusion lasting 4 h. Control of shRNA mediated knockdown of SQOR expressing adeno-associated viral vectors were administered 3 weeks prior to liver ischemia. In the shRNA-mediated knockdown of SQOR group, the hydro-trisulfide donor sodium trisulfide was administered daily for 1 week prior to the induction of liver ischemia. SQOR played a crucial protective role during hepatic IRI by facilitating electron transport to the mitochondrial respiratory chain and maintaining the oxidized and reduced nicotinamide adenine dinucleotide ratio. Administration of sodium trisulfide, exhibited protective effects against hepatic IRI. Sodium trisulfide restored the oxidized and reduced nicotinamide adenine dinucleotide ratio, reduced oxidative stress, and preserved the expression of key enzymes involved in the sulfide oxidation pathway. SQOR and supersulfides contribute to hepatic protection against IRI, likely through their potent antioxidative and redox-regulating functions, and highlight sodium trisulfide as a potential therapeutic agent.

The number of elderly people transported to the emergency department with respiratory failure is increasing. Some do not wish to receive invasive interventions, but when patients are unconscious, determining their treatment preferences can be challenging. Asymmetric nasal high-flow (NHF) therapy is a non-invasive respiratory support method that has shown effectiveness in type II respiratory failure, although there are no prior reports on its use for carbon dioxide (CO₂) narcosis. We report a case in which asymmetric NHF therapy was effective for CO₂ narcosis triggered by pneumonia in an elderly patient. A 96-year-old man with impaired consciousness was brought to the emergency department. Arterial blood gas analysis revealed respiratory acidosis, and imaging confirmed the presence of pneumonia and CO₂ narcosis secondary to pneumonia. Given the patient's advanced age, the goal was to avoid invasive intubation. Non-invasive ventilation (NIV) was considered, but deemed unsuitable because of excessive sputum and impaired consciousness. Therefore, asymmetric NHF therapy was initiated. The patient became responsive within 40 minutes, and his respiratory acidosis improved. After regaining consciousness, the treatment plan was discussed with the patient, and antibiotic therapy and asymmetric NHF were continued. For elderly patients, patient preference should be taken into account when making airway management decisions. Although NIV is commonly used for CO₂ narcosis, it is not suitable for certain patients, such as patients with excessive sputum and impaired consciousness. Asymmetric NHF is a noninvasive option that may help reduce the partial pressure of arterial CO2 and improve consciousness. This case suggests that asymmetric NHF may be a valuable therapeutic option for CO₂ narcosis in the elderly.

INTRODUCTION:The shortage of organ donors is a major challenge in transplantation. Expanding donor eligibility criteria can help increase the donor pool, but it is crucial to carefully assess the risks related to infections in donors with expanded criteria. Organ donation from trauma patients who have undergone open abdominal management (OAM) is uncommon because of concerns regarding organ damage and infection risk. However, with appropriate OAM and stringent infection control, safe organ donation may be possible. CASE PRESENTATION:We herein present a case involving a patient who sustained abdominal organ injuries and head trauma from a fall. Emergency laparotomy was performed, including splenectomy for a splenic injury and liver laceration repair, followed by OAM using ABTHERA (3M Health Care, St. Paul, MN, USA). The patient subsequently developed irreversible brain damage and was declared brain dead. The patient's family consented to organ donation. Following thorough evaluation, the heart, lungs, and liver were successfully recovered and transplanted into recipients at three different institutions, with no severe infections or rejection episodes reported. CONCLUSIONS:This case illustrates that with proper management using ABTHERA in OAM, organ donation can be safely achieved even in challenging cases involving trauma patients.

Streptococcal toxic shock syndrome (STSS) is an invasive Streptococcus pyogenes infection characterized by hypotension and multiple organ failure with rapid progression and high mortality. Although extracorporeal membrane oxygenation (ECMO) has been used in adults with STSS, mortality remains high and optimal mechanical circulatory support is controversial. Veno-arterial ECMO has specific complications in severe cardiopulmonary failure, including differential hypoxia and increased left ventricular end-diastolic pressure due to retrograde flow. A 51-year-old man presented to the emergency department with fever and dyspnea, progressing rapidly from an initially diagnosed upper respiratory tract infection to severe respiratory distress and refractory shock requiring oxygen supplementation and vasopressor support. The patient was diagnosed with STSS, which manifested as septic shock with severe cardiopulmonary compromise. We implemented a combined approach using veno-arteriovenous ECMO (V-AV ECMO) and Impella CP® support (veno-arteriovenous extracorporeal membrane oxygenation and Impella [VAVEcpella]). This strategy provided oxygenated blood to the right heart while achieving left ventricular unloading. This was done in conjunction with appropriate antibiotic therapy and source control measures. The novel VAVEcpella approach successfully supported the patient through severe cardiopulmonary failure secondary to STSS-induced septic shock. To our knowledge, this is the first reported case of VAVEcpella implementation specifically for the management of STSS. The VAVEcpella approach (combined V-AV ECMO and Impella support) may represent a viable rescue strategy for patients with severe cardiopulmonary failure secondary to septic shock, such as STSS, where traditional support methods have shown limited success.

Esophageal varices are common in cirrhosis with portal hypertension; some patients face high risk of life-threatening esophageal variceal bleeding (EVB). Because few noninvasive markers predict EVB, this study sought to identify accessible predictors. From 2002 to 2018, 336 patients with high-risk or hemorrhagic esophageal varices were studied: 72 with recent variceal rupture/bleeding (EVB) and 264 without (EVNB). The study evaluated associations between EVB and several clinical scores and biomarkers, focusing on sarcopenia, Controlling Nutritional Status (CONUT) score, and neutrophil-to-lymphocyte ratio (NLR), alongside established indices. Comparisons and univariate analyses were performed for MELD, CONUT, sarcopenia, fibrosis index, FIB-4, AST/ALT ratio, ALBI, and APRI between EVB and EVNB groups. Multivariate analysis identified the Neutrophil/Lymphocyte ratio (NLR) and CONUT score were identified as independent predictors associated with EVB. The CONUT score and NLR achieved AUROCs values were 0.75 and 0.65, with optimal cut-offs at 4.5 and 3.87, respectively. Notably, 58/72 (80.6

Intensive care unit-acquired weakness (ICU-AW) is recognized as newly-acquired bilateral muscle weakness, which is a complication of critical illness in the ICU; however, there are no reports on the pathogenesis and early predictors of ICU-AW specifically associated with cardiogenic shock (CS). Therefore, this study aimed to investigate the clinical characteristics of ICU-AW in patients with CS requiring mechanical circulatory support (MCS). This study was a single-center, prospective, and observational study. Patients aged 16 years and older who underwent MCS for CS were included. ICU-AW was diagnosed based on Medical Research Council (MRC) score after awakening. The ICU-AW group included patients with the MRC score < 48 points, and the non-ICU-AW group included those with ≥ 48 points. Twenty-eight cases were enrolled on admission and MRC score was evaluated in 23 cases after awakening. Eleven patients were included in the non-ICU-AW group and 12 patients (52%) were in the ICU-AW group. The ICU-AW group showed a higher prevalence of extracorporeal membrane oxygenation and ventilator use. Creatine kinase, troponin T, interleukin (IL)-15 levels on admission were significantly higher, whereas hemoglobin and albumin levels were significantly lower in the ICU-AW group. A strong negative correlation was observed between the initial MRC scores and IL-15 levels. ICU-AW occurred 52% of patients with CS using MCS, indicating the significance of recognizing and managing this complication for those patients. In addition, IL-15 can be a potential biomarker for the early prediction of ICU-AW.

This is the English version of the guidelines for the diagnosis and treatment of idiopathic portal hypertension, extrahepatic portal obstruction, and Budd-Chiari syndrome, which were established and revised in 2018 by the Aberrant Portal Hemodynamics Study Group under the jurisdiction of the Ministry of Health, Labor, and Welfare in Japan. These guidelines are excerpts, and the full version consists of 86 clinical questions and explanations, totaling 183 pages in Japanese.

Surgical cameras and endoscopes provide important imaging information about a patient's anatomy and pathology, but most of the data are limited to 2D textured representations of visible tissue surfaces. Conversely, research is progressing in the information acquisition field by using spectrum data to obtain more detailed disease diagnostic support information. Spectroscopic information reflects the chemical and physical information of substances. Research is expanding from conventional single-point spectroscopic information to acquisition of two-dimensional spectroscopic information, called hyperspectral data. However, this type of information typically takes a relatively long time to acquire and analyze, which has limited its practical use. Particularly, compensation for the continuous motions of the camera and tissue occurring during acquisition of numerous images as well as the analysis time slow delivery of real-time information. Due to these disadvantages, the use of analyzed hyperspectral data information in medicine has been limited to the research stage. This study aimed to use this system to visualize blood phantoms and biological information from small animals. We developed a 3-band spectral imaging method for measuring relative blood concentration and oxygen saturation, and modified white light images. Real-time information display is possible by limiting the target information and speeding up image acquisition and processing. We also developed an existing red-green-blue (RGB) wavelength-band digital imaging system, in which an optical filter is used to limit the wavelength range to effectively capture the spectral changes associated with oxygen saturation and concentration. Since the three-wavelength information is in the wavelength range of the RGB channels of the image sensor, single-frame data capture was achieved. An analytical method for 3-band spectral data was also developed, which contributed to fast image processing. Further development of this technology can eliminate the disadvantages associated with conventional spectroscopic imaging and analysis. Consequently, we expect that it will contribute to practical use of spectral information in the medical field. The method developed in this study can be applied to general purpose cameras and is highly practical as a display technology for diagnostic support information.

Objectives: To develop an equation for defining a low skeletal muscle mass (SMM) in children and to investigate risk factors and outcomes associated with low SMM in critically ill pediatric patients. Design: Single-center retrospective pediatric cohorts, 2011–2018. Setting: Tertiary Emergency and Critical Care Center of Kyushu University Hospital in Japan. Patients: We studied two cohorts of pediatric patients 1–15 years old who underwent abdominal CT at the level of the third lumbar vertebra (L3). First a cohort of trauma patients presented to the emergency department in whom we developed an SMM regression equation. Second, a cohort of patients who had undergone abdominal CT within 3 days of PICU admission. Interventions: None. Measurements and Main Results: The equation for estimating normal SMM used sex, age, and weight. Low SMM was defined as less than 80% of normal. In the 112 patients in the PICU cohort, median (range) age was 68 (13–191) months, and 83 (74.1%) had underlying disease. There was low SMM in 54 patients (48.2%). Regarding associations, using odds ratio (OR) and 95% CI, we found that low dietary intake (OR 4.33 [95% CI, 1.37–13.70]; p = 0.013) and the presence of underlying disease (OR 7.44 [95% CI, 2.10–26.30]; p = 0.002) were independently associated with greater odds of low SMM. Low SMM, compared with normal SMM, was also associated with longer hospital stays (42.5 d vs. 20.5 d; p = 0.007; β, 1.59; 95% CI, 1.09–2.33; p = 0.016). Conclusions: In this retrospective PICU cohort from a single center in Japan, we found that low SMM at PICU admission was present in almost half the cases. Low SMM, as defined by being less than 80% of the normal, was associated with greater odds of low dietary intake and underlying chronic disease. Furthermore, low SMM was associated with longer hospital stays.

Pelvic fractures, accounting for 2–8% of skeletal injuries, present a significant burden in patients with trauma. High-energy incidents often result in severe pelvic trauma accompanied by comorbidities leading to high mortality rates. Managing these complications adds complexity to the treatment process, particularly in older patients who experience longer recovery times and higher injury severity. To improve the long-term quality of life, a multidisciplinary approach is essential. However, rehabilitation feasibility is influenced by the patient’s condition and pelvic fixation stability, necessitating individualized treatment. This study investigated the rehabilitation status and long-term outcomes of older patients with severe polytrauma and pelvic ring fractures caused by high-energy trauma. The results revealed that 79.2% of the patients achieved full weight-bearing, with a median time of 41.5 days, and eventually 58.3% were discharged home. Complications were observed in 83.3% of the patients, with various challenges affecting successful home discharge. Multidisciplinary rehabilitation programs are promising for optimizing outcomes and facilitating recovery in vulnerable patient populations. Still, larger, more focused studies are needed to gain more comprehensive insights into the treatment and recovery of older patients with pelvic ring fractures and severe polytrauma. Understanding these factors is crucial for guiding clinical decision-making and improving long-term outcomes in this population.

BackgroundSympathetic nerve activity (SNA) plays a central role in the pathogenesis of several diseases such as sepsis and chronic kidney disease (CKD). Activation of microglia in the paraventricular nucleus of the hypothalamus (PVN) has been implicated in SNA. The mechanisms responsible for the adverse prognosis observed in sepsis associated with CKD remain to be determined. Therefore, we aimed to clarify the impact of increased SNA resulting from microglial activation on hemodynamics and organ damage in sepsis associated with CKD.Methods and resultsIn protocol 1, male Sprague-Dawley rats underwent either nephrectomy (Nx) or sham surgery followed by cecal ligation and puncture (CLP) or sham surgery. After CLP, Nx-CLP rats exhibited decreased blood pressure, increased heart rate, elevated serum creatinine and bilirubin levels, and decreased platelet count compared to Nx-Sham rats. Heart rate variability analysis revealed an increased low to high frequency (LF/HF) ratio in Nx-CLP rats, indicating increased SNA. Nx-CLP rats also had higher creatinine and bilirubin levels and lower platelet counts than sham-CLP rats after CLP. In protocol 2, Nx-CLP rats were divided into two subgroups: one received minocycline, an inhibitor of microglial activation, while the other received artificial cerebrospinal fluid (CSF) intracerebroventricularly via an osmotic minipump. The minocycline-treated group (Nx-mino-CLP) showed attenuated hypotensive and increased heart rate responses compared to the CSF-treated group (Nx-CSF-CLP), and the LF/HF ratio was also decreased. Echocardiography showed larger left ventricular dimensions and inferior vena cava in the Nx-mino-CLP group. In addition, creatinine and bilirubin levels were lower and platelet counts were higher in the Nx-mino-CLP group compared to the Nx-CSF-CLP group.ConclusionsIn septic rats with concomitant CKD, SNA was significantly enhanced and organ dysfunction was increased. It has been suggested that the mechanism of exacerbated organ dysfunction in these models may involve abnormal systemic hemodynamics, possibly triggered by activation of the central sympathetic nervous system through activation of microglia in the PVN.

ABSTRACT:Background: Histidine-rich glycoprotein (HRG), a potential prognostic factor in sepsis, lacks clarity regarding its relevance in septic-induced shock, disseminated intravascular coagulation (DIC), and acute respiratory distress syndrome (ARDS) pathogenesis. This study investigated the association between HRG concentrations and these critical conditions. Methods: Blood samples were collected from 53 critically ill patients on days 1, 3, 5, and 7 after ICU admission at the Kyushu University Hospital. Daily clinical and laboratory data were recorded, and patient survival was assessed 28 days after ICU admission. Results: Serum HRG concentrations were significantly reduced on days 3, 5, and 7 in patients with septic shock and DIC but not in those with ARDS. While initial HRG levels on day one were not correlated with survival, nonsurvivors displayed decreased HRG levels, notably on days 3, 5, and 7 post-ICU admissions. The HRG levels remained stable in survivors. A progressive decrease was associated with higher mortality rates, particularly on days 5 and 7. On day 5, an HRG level with a cutoff of 25.5 μg/mL showed a sensitivity of 0.77 and a specificity of 0.75, indicating significantly lower survival rates (log-rank test, P < 0.05). Conclusion: HRG presents a potential intervention for critically ill sepsis patients, providing a novel strategy to enhance outcomes. Further research is needed to explore the therapeutic potential of HRG in sepsis management.

Myxomas are the most common benign primary cardiac tumor. Their clinical presentation can vary, ranging from asymptomatic to constitutional symptoms, obstructive or embolic symptoms. These can even be life-threatening sometimes. Here, we report a case of an elderly female with exertional breathlessness, which turned out to be a large left atrial myxoma, diagnosed using a point of care ultrasound.

Recombinant antithrombin gamma (rAT) is reported as an effective drug for patients with disseminated intravascular coagulation (DIC) in Japan. As the appropriate dose and targeted AT activity remain unknown, this study aimed to determine these aspects for sepsis-induced DIC. Thirty-one patients with septic shock and DIC with AT levels <70% were treated with rAT between May 2018 and December 2020. The recovery rates from DIC were 32.2% and 63.3% on day 3 and 5 post administration, respectively. Recovery and survival rates were significantly higher in patients who achieved AT activity ≥70% or 80% on day 3 post administration. Receiver operating characteristic curve analysis revealed that the cutoff values of post-treatment AT activity on day 3 for 28-day survival and 5-day recovery from DIC were 79.5% and 81.5%, respectively. Patients who did not achieve AT activity ≥80% on day 3 presented a lower base level of AT activity and lower dose supplementation. Our results suggest that targeted AT activity should be at least 70%, and ideally 80%, and sufficient doses to maintain this activity are required to achieve better outcomes.

Gastrointestinal cancer can be treated using a flexible endoscope through a natural orifice. However, treatment instruments with limited degrees of freedom (DOFs) require a highly skilled operator. Articulated devices useful for endoluminal procedures, such as endoscopic submucosal dissection and biopsy, have been developed. These devices enable dexterous operation in a narrow lumen; however, they suffer from limitations such as large size and high cost. To overcome these limitations, we developed a 2.5-mm articulated forceps that can be inserted into a standard endoscope channel based on a compliant mechanism. The compliant mechanism allows the device to be compact and affordable, which is possible due to its monolithic structure. The proposed mechanism consists of two segments, 1-DOF grasping and 2-DOF bending, that are actuated by tendon-sheath mechanisms. A prototype was designed based on finite element analysis results. To confirm the effectiveness of the proposed mechanism, we fabricated the prototype using a 3D printer. A series of mechanical performance tests on the prototype revealed that it achieved the following specifications: (1) DOF: 1-DOF grasping + 2-DOF bending, (2) outer diameter: 2.5 mm, (3) length of the bending segment: 30 mm, and (4) range of motion: 0^∘ to 20^∘ (grasping) and - 90^∘ to + 90^∘ (bending). Finally, we performed a tissue manipulation test on an excised porcine colon and found that a piece of mucous membrane tissue was successfully resected using an electric knife while being lifted with the developed forceps. The results of the evaluation experiment demonstrated a positive feasibility of the proposed mechanism, which has a simpler structure compared to those of other conventional mechanisms; furthermore, it is potentially more cost-effective and is disposable. The mechanical design, prototype implementation, and evaluations are reported in this paper.